Work Group 2 KMC in Low Resource setting

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Work Group 2KMC in Low Resource setting

• Members
• Adriano Cattaneo
• Ochi Ibe
• Nancy Sloan
• Hadi Pratomo
• Joseph de Graft Johnson
• Evely Zimba
• Suman Rao
• Saluddin Ahmed
• Nagai Shuko
• Zita de Calume
• Steve Wall
• THU NGA NGUYEN
• MUKESH GUPTA

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Rationale for the group work

• To respond to WHOs needs to facilitate revision
  of KMC guidelines
• Originally composed in 1998-1999, published 2003,
• Due to recent publication of standards for
  guidelines development in the Lancet.
• The new WHO guidelines will focus on what should
  be done for KMC, universally. Other tools will
  have to be developed alongside the new guidelines
  on how to implement KMC in high and low tech
  settings, and at community level, and on how to
  use KMC for early child development. Tools will
  also be needed for advocacy, integration within
  health systems and services, training (pre- and
  in-service), monitoring and evaluation.
• This working group worked to provide ideas and
  experience on how to proceed with the development
  of the above guidelines and tools from the point
  of view of low income settings and communities

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The topics the group discussed are

• What is universally needed, e.g., position,
  feeding, follow-up, friendly environment
• How to implement at different levels, e.g.,
  referral hospital, primary level, community
• Minimum Resources needed (requirements) for
  implementation

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What is universally needed

• Skin to Skin (kangaroo Position)
• The earlier after birth, the better (sensitive
  period in the first two hours of life can be
  done later, but it will be increasingly difficult
  and less effective)
• In all full term healthy newborn infants (see the
  BFHI and other WHO documents, let alone the
  abundant literature not to be discussed further)
• In all preterm and LBW newborn infants (likely
  positive effect on physiological stability what
  is meant by stable newborn infant?)
• As continuous as possible (ideally day and night
  over 24 hours), intermittent STS being a lower
  quality alternative in case of prematurity if
  there is no alternative means of keeping baby
  warm) (but some STS is better than no STS,
  provided each session lasts at least an hour, and
  efforts are put in place to achieve continuous
  STS)
• For as long as possible (until spontaneous
  weaning off by the baby)
• In the frontal position (oxytocin receptors),
  vertical or semi-reclined (also at night), diaper
  or local surrogate only (keep mother and baby
  dry), head covered in cold climate (but allow
  STS)

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• Skin to Skin (kangaroo Position)
• STS needed also in hot wet climate (hypothermia
  frequent also in these settings) if mothers
  complain, help them keep dry (change clothes,
  cool, ventilate, use shade, etc) if needed,
  allow few hours with light cotton cloth between
  mother and baby during hottest day hours do not
  bath dry clean the baby
• With appropriate containment (lycra band or other
  local culturally and economically acceptable
  material)
• Postioning technique must ensure the newborn has
  a patent airways
• Primarily by the mother, but father and other
  designated family members (limited number) can
  replace the mother when needed
• STS provides comfort and promotes attachment and
  parental bonding, with positive maternal and
  paternal reaction and involvement, as well as
  acceptance (mediated by oxytocin)
• STS and KMC promote good quality hospital
  neonatal care and NICU environment (humanization,
  mother and family centred care)

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What is universally Needed (ii)

• Breastfeeding (BF)/Breastmilk
• All full term newborn infants immediately at the
  breast for first latch as soon as the baby is
  ready, without forcing to the nipple, allowing
  time as needed (see BHFI not to be discussed
  further)
• All preterm and LBW newborn infants at the breast
  as early as possible, to stimulate lactation even
  if latching and sucking do not occur
• If the baby is unable to breastfeed (suck,
  swallow), start expressing colostrum and
  breastmilk as soon as possible and use to feed
  the baby (use clean syringe, teaspoon or other
  appropriate tool) avoid prelacteal feeds
• If unable to breastfeed and not fed properly,
  give some glucose solution in first 24-48 hours
  to avoid hypoglycemia
• Scheduled and/or semi-demand feeding needed in
  all preterm and LBW infants until exclusive
  breastfeeding is well established and adequate
  growth is observed
• In case of inadequate growth, try to increase
  breastmilk production, use hindmilk, use donor
  safe breastmilk is available if no breastmilk
  available, use preterm formula (national
  guidelines and hospital protocols) BF support in
  preterm and LBW infants need health workers with
  special skills
• For HIV, follow national guidelines, no special
  KMC policy

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What is universally Needed (iii)

• Universal (?free) access to effective health care
  for preterm and LBW infants, better if in a
  preterm/LBWI friendly hospital (certification
  like BFHI? With different grades of achievement
  to show that progress is rewarded?) with

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Steps to preterm/LBWI friendly hospital
(certification like BFHI?

• Written KMC policy know to all staff and parents
• Health workers (including auxiliaries) trained to
  implement policy
• Information on KMC for all pregnant women
• Adequate KMC routines for all preterm/LBWI
• Adequate follow up (ambulatory or in continuity
  with health care system) with established
  criteria (ability to suck and feed, gaining
  weight, no disease, parents prepared to KMC at
  home) as close as possible to home to improve
  compliance (frequency will depend on age and
  weight gain)
• Adequate links with family and community for
  social support
• Better if all this is included in national
  policies and plans for essential newborn care
  (pilot phase, assessment, identification of
  obstacles and problems, find solution, expansion,
  monitor process and results) follow technology
  assessment procedures, but keep in mind the
  behavioural component of KMC
• Essential if community-based KMC is implemented
• Integrate with other components of maternal and
  child health (antenatal care, care at childbirth,
  postnatal care, early childhood development)

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What is universally Needed (iv)

• Social support and friendly environment
• Promote mother-to-mother support
• Try to overcome physical and economic obstacles
• Empower families and promote in neighbourhoods
• Positive representation in mass media
• National supportive legislation (maternity leave
  and protection)

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How to implement at different levels, including
resources needed and essential requirements
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Secondary and tertiary referral hospitals....i

• Necessary if you want to implement KMC at lower
  and community levels a good programme at this
  level will facilitate extension
• Have written policy and train all staff to
  implement it involve obstetricians,
  anesthesiologists, auxiliaries etc a BFHI
  accreditation will facilitate KMC
• Let pregnant women and all hospital users know
  about the policy (appropriate written and
  pictorial materials)
• Essential equipment and supplies are needed
  incubator, radiant warmer, oxygen and flowmeters,
  pulse oxymeter, CPAP, phototherapy, lab tests,
  drugs, micronutrients, i.v. fluids, facilities
  for expressed breastmilk, preterm formula, cups,
  feeding tubes, scales (10 g precision),
  refrigerator, etc but also leisure room for
  mothers to socialize, read, chat, play, watch TV,
  knit, etc involve fathers

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Secondary and tertiary referral hospitals....ii

• Use available facilities and resources (rooms,
  staff, equipment, money, etc) and reallocate,
  rather than request new facilities and resources
• Ensure that KMC staff has the necessary skills to
  support BF in preterm/LBWI
• Ensure adequate follow up, ambulatory or at
  peripheral facilities depending on distance and
  circumstances (hence the need to train also
  health workers in lower level facilities), ensure
  continuity of care
• Keep good records and use database to assess
  quantity and quality of KMC, as well as outcomes

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First level Hospitals (with admission policy)

• Clear criteria about which preterm/LBWI will be
  cared for at which level, so that only those
  appropriate for this level will remain here, or
  will be sent here after discharge from secondary
  or tertiary care unit
• Link with secondary/tertiary unit, but also with
  lower level health centres and facilities
• Have a written policy, inform and train all
  staff, inform all pregnant women and their
  families
• Have a minimal package of materials, equipment
  and supplies that will allow to care and monitor
  larger preterm/LBWI (or smaller preterm/LBWI
  discharged from secondary/tertiary units) for few
  days to monitor health and growth, before
  discharge home
• Be equipped, including trained staff, to deal
  with special breastfeeding support needed for KMC
  infants
• Keep good records

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Other first level facilities

• Differentiate care provided according to
  capability for inpatient care, although limited,
  or not for example can cases of neonatal sepsis
  be treated or will they be referred to upper
  level facility?
• If no inpatient care, train staff to follow up
  (including outreach if necessary) preterm/LBWI
  discharged from upper levels or referred from
  CHW/V (see below)
• Weighing, monitoring growth, counseling, etc
  should be possible in these and upper level
  facilities, with appropriate equipment and
  supplies, including simple management and triage
  (staff must be trained for all this make sure
  staff does not go beyond what they have been
  trained to do for preterm/LBWI)
• Keep simple records, ensure regular supervision,
  have simple pictorial instructional material
  (IMCI-like)

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Community KMC

• In settings where percentage of births assisted
  by skilled attendants is low and unlikely to grow
  rapidly
• Start simultaneously with KMC in health care
  facilities (see above) and teaching institutions
  do not use community KMC to delay access to
  quality health care services
• For all newborn infants or only for preterm/LBW
  (small) infants, depending on countries and
  circumstances (GA impossible to assess
  everywhere BW impossible to get in most places
  where scales are available, may only have
  colour-coded gross indication of weight
  categories no accurate measures colour-coded
  assessment of mid arm circumference may be an
  alternative)

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Community KMC..contd 2

• About 500-1500 (based on distances) population
  per CHW/V (larger populations difficult to
  manage) with a comprehensive but not excessive
  and unmanageable number of tasks
• Community sensitised with culturally adapted
  social communication for behavioural change that
  creates a favourable environment (see recent
  Lancet paper by V. Kumar) integrate traditional
  birth attendants
• Start with information for all pregnant women,
  with appropriate instructions and pictorial
  material (1-2 visits in pregnancy), counselling
  materials and skills
• Promote birth in preterm/LBW friendly hospital in
  case of preterm labour and birth, or refer to
  hospital soon after birth (clear criteria for
  referral in training and instructions) use STS
  for transport, while maintaining BF

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Community KMC..contd 3

• Promote as early as possible STS (first 24 hours,
  maximum 48 hours) and as continuous as possible
• Promote adequate personal hygiene for the mother
  who is providing KMC
• Ensure a CHW/V visit as soon as possible after
  birth (same timing) then visit every two days in
  first week and for a total of five times in the
  first month observe BF and give adequate support
  at every visit promote scheduled and/or
  semi-demand feeding until baby sucks and feed
  well and good growth is confirmed
• Use simple checklists for both ante- and
  postnatal care, so that essential observation and
  advice is not missed identify danger signs and
  refer accordingly
• Community (and even ambulatory or facility based)
  follow up after hospital discharge may be
  particularly difficult in peri-urban slum areas
  special efforts needed

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Community KMC..contd 4

• If for all newborn infants, monitor adverse
  events (unexpected and unexplained deaths
  reported in France and UK) the baby may be used
  to identify which needs STS beyond sensitive
  period term babies will push away)
• Provided by community health workers or
  volunteers (CHW/V), male or female, paid or
  unpaid, employed by governments or NGOs, with a
  given educational level, depending on
  circumstances credible in the community
• CHW/V appropriately trained competency based
  courses of adequate duration (2-3 weeks?)
• CHW/V with essential equipment (scale?
  thermometer? drugs? mobile phone?) and simple
  records and adequate supervision to maintain or
  improve quality performance

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Key take home messages

• For advocacy

• Integrate KMC in to Essential newborn care

• For sustainability
• think about cost
• plan accordingly (never as stand alone KMC, but
  as part of comprehensive newborn care),
• Provide accurate information that survival may
  improve, but deaths will still occur, and that
  survivors may have a better life.

• Involve governments and donors, set up local
  partnerships
• Have champion to help sustain enthusiasm (and
  deal with anti champions)
• Award, certify, reward (as in BFHI or better)
• Present as part of comprehensive integrated ENC
• Get WHO and UNICEF support